Provider Demographics
NPI:1255765855
Name:MOSHER, SUSAN BEATRICE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BEATRICE
Last Name:MOSHER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5934 W MIDWAY PARK
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-1845
Mailing Address - Country:US
Mailing Address - Phone:773-287-0441
Mailing Address - Fax:
Practice Address - Street 1:120 S MARION ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2809
Practice Address - Country:US
Practice Address - Phone:708-383-7500
Practice Address - Fax:708-383-7780
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490062711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical